Refractory depression - mechanisms and efficacy of radically open dialectical behaviour therapy (RefraMED): findings of a randomised trial on benefits and harms.

BACKGROUND: Individuals with depression often do not respond to medication or psychotherapy. Radically open dialectical behaviour therapy (RO DBT) is a new treatment targeting overcontrolled personality, common in refractory depression. AIMS: To compare RO DBT plus treatment as usual (TAU) for refractory depression with TAU alone (trial registration: ISRCTN 85784627). METHOD: RO DBT comprised 29 therapy sessions and 27 skills classes over 6 months. Our completed randomised trial evaluated RO DBT for refractory depression over 18 months in three British secondary care centres. Of 250 adult participants, we randomised 162 (65%) to RO DBT. The primary outcome was the Hamilton Rating Scale for Depression (HRSD), assessed masked and analysed by treatment allocated. RESULTS: After 7 months, immediately following therapy, RO DBT had significantly reduced depressive symptoms by 5.40 points on the HRSD relative to TAU (95% CI 0.94-9.85). After 12 months (primary end-point), the difference of 2.15 points on the HRSD in favour of RO DBT was not significant (95% CI -2.28 to 6.59); nor was that of 1.69 points on the HRSD at 18 months (95% CI -2.84 to 6.22). Throughout RO DBT participants reported significantly better psychological flexibility and emotional coping than controls. However, they reported eight possible serious adverse reactions compared with none in the control group. CONCLUSIONS: The RO DBT group reported significantly lower HRSD scores than the control group after 7 months, but not thereafter. The imbalance in serious adverse reactions was probably because of the controls' limited opportunities to report these.

Ameliorating Patient Stigma Amongst Staff Working With Personality Disorder: Randomized Controlled Trial of Self-Management Versus Skills Training.

BACKGROUND: Patients diagnosed with a personality disorder (PD) are often stigmatized by the healthcare staff who treat them. AIMS: This study aimed to compare the impact on front-line staff of a self-management Acceptance and Commitment Therapy-based training intervention (ACTr) with a knowledge- and skills-based Dialectical Behaviour Training intervention (DBTr). METHOD: A service-based randomized controlled trial was conducted comparing the effects of 2-day ACTr (N = 53) and DBTr (N = 47) staff workshops over 6 months. Primary outcome measures were staff attitudes towards patients and staff-patient relationships. RESULTS: For both interventions, staff attitudes, therapeutic relationship, and social distancing all improved pre- to postintervention, and these changes were maintained at 6-month follow-up. CONCLUSIONS: Although offering different resources to staff, both ACTr and DBTr were associated with an improved disposition towards PD patients. Future research could evaluate a combined approach, both for staff working with PD patients and those working with other stigmatized groups.

An experimental investigation of emotional willingness and physical pain tolerance in deliberate self-harm: the moderating role of interpersonal distress.

Although theoretical and clinical literature emphasize the role of both an unwillingness to experience emotional distress and physical pain tolerance in deliberate self-harm (DSH), research on their associations with DSH remains limited. This study sought to examine the relationships between DSH and the willingness to experience emotional distress and tolerate physical pain, including the moderating role of interpersonal distress in these relationships. To this end, young adults with recent DSH (n = 43) and controls without any DSH (n = 52) were randomly assigned to 1 of 2 emotion-induction conditions (distressing or neutral), after which behavioral measures of both the willingness to experience distress and physical pain tolerance were obtained. Consistent with hypotheses, findings indicated heightened physical pain tolerance among self-harming individuals only under conditions of interpersonal distress. Furthermore, findings provided some support for the hypothesized association between DSH and the unwillingness to experience emotional distress, suggesting that self-harming women evidence less willingness to experience emotional distress only under conditions of depleted regulatory capacity (eg, following an interpersonal stressor).

Developing and validating the "composite measure of problem behaviors".

Clinicians frequently encounter problem behaviors such as self-harm, restrictive eating, binge eating, alcohol misuse, drug misuse, smoking, sexual promiscuity, internet addiction, excessive exercise, and aggression. Although these behaviors commonly co-occur, no scale exists to measure them concurrently. Based on data from two opportunity samples (N = 691 and N = 53), this study designed and validated a composite measure of the problem behaviors noted above. The Composite Measure of Problem Behaviors, developed using exploratory factor analysis, demonstrated good psychometric properties. Subsequent confirmatory factor analysis, using both the first (N = 691) and a third sample (N = 740), identified a common higher order factor that accounted for covariance between behaviors. Findings thus suggest that despite the formal dissimilarity of behaviors assessed, a common function may explain their covariation.

Parents' experiences of home-based applied behavior analysis programs for young children with autism.

Although much research has documented the benefits to children with autism of early intensive behavioral intervention (EIBI), little has focused on the impact of EIBI on families. Using a semi-structured format, we interviewed 53 parents whose children had received 2 years of EIBI to obtain detailed first person accounts of the perceived benefits and pitfalls of running a home program, and the impact of EIBI on family life and support systems. In general, parents were positive about EIBI, its benefits for them, their child, and the broader family. Interviews also, however, revealed some of the more challenging aspects of managing home-based EIBI. The implications of these findings for more supportive interventions for families on home programs are discussed.

Refractory depression - cost-effectiveness of radically open dialectical behaviour therapy: findings of economic evaluation of RefraMED trial.

BACKGROUND: Refractory depression is a major contributor to the economic burden of depression. Radically open dialectical behaviour therapy (RO DBT) is an unevaluated new treatment targeting overcontrolled personality, common in refractory depression, but it is not yet known whether the additional expense of RO DBT is good value for money.AimsTo estimate the cost-effectiveness of RO DBT plus treatment as usual (TAU) compared with TAU alone in people with refractory depression (trial registration: ISRCTN85784627). METHOD: We undertook a cost-effectiveness analysis alongside a randomised trial evaluating RO DBT plus TAU versus TAU alone for refractory depression in three UK secondary care centres. Our economic evaluation, 12 months after randomisation, adopted the perspective of the UK National Health Service (NHS) and personal social services. It evaluated cost-effectiveness by comparing the net cost of RO DBT with the net gain in quality-adjusted life-years (QALYs), estimated using the EQ-5D-3L measure of health-related quality of life. RESULTS: The additional cost of RO DBT plus TAU compared with TAU alone was £7048 and was associated with a difference of 0.032 QALYs, yielding an incremental cost-effectiveness ratio (ICER) of £220 250 per QALY. This ICER was well above the National Institute for Health and Care Excellence (NICE) upper threshold of £30 000 per QALY. A cost-effectiveness acceptability curve indicated that RO DBT had a zero probability of being cost-effective compared with TAU at the NICE £30 000 threshold. CONCLUSIONS: In its current resource-intensive form, RO DBT is not a cost-effective use of resources in the UK NHS.Declaration of interestR.H. is co-owner and director of Radically Open Ltd, the RO DBT training and dissemination company. D.K. reports grants outside the submitted work from the National Institute for Health Research (NIHR). T.L. receives royalties from New Harbinger Publishing for sales of RO DBT treatment manuals, speaking fees from Radically Open Ltd, and a grant outside the submitted work from the Medical Research Council. He was co-director of Radically Open Ltd between November 2014 and May 2015 and is married to Erica Smith-Lynch, the principal shareholder and one of two directors of Radically Open Ltd. H.O'M. reports personal fees outside the submitted work from the Charlie Waller Institute and Improving Access to Psychological Therapy. S.R. provides RO DBT supervision through her company S C Rushbrook Ltd. I.R. reports grants outside the submitted work from NIHR and Health & Care Research Wales. M. Stanton reports personal fees outside the submitted work from British Isles DBT Training, Stanton Psychological Services Ltd and Taylor & Francis. M. Swales reports personal fees outside the submitted work from British Isles DBT Training, Guilford Press, Oxford University Press and Taylor & Francis. B.W. was co-director of Radically Open Ltd between November 2014 and February 2015.

DTkid: interactive simulation software for training tutors of children with autism.

Discrete-trial training (DTT) relies critically on implementation by trained tutors. We report three experiments carried out in the development of "DTkid"--interactive computer simulation software that presents "SIMon", a realistic virtual child with whom novice tutors can learn and practise DTT techniques. Experiments 1 and 2 exposed groups of participants either to DTkid training or to a control task. Participants in the former groups demonstrated significantly greater procedural and declarative knowledge of DTT. Experiment 3 confirmed this finding, further demonstrating that observation of DTkid training trials alone was sufficient to enhance participants' declarative and procedural knowledge of DTT. Results indicate that DTkid offers the potential for an effective means of teaching DTT skills to novice tutors of children with autism.

Early intensive behavioral intervention: outcomes for children with autism and their parents after two years.

An intervention group (n=23) of preschool children with autism was identified on the basis of parent preference for early intensive behavioral intervention and a comparison group (n=21) identified as receiving treatment as usual. Prospective assessment was undertaken before treatment, after 1 year of treatment, and again after 2 years. Groups did not differ on assessments at baseline but after 2 years, robust differences favoring intensive behavioral intervention were observed on measures of intelligence, language, daily living skills, positive social behavior, and a statistical measure of best outcome for individual children. Measures of parental well-being, obtained at the same three time points, produced no evidence that behavioral intervention created increased problems for either mothers or fathers of children receiving it.

Equivalence relations, contextual control, and naming.

This paper reports two experiments that investigated the role of verbal behavior in the emergence and generalization of contextually controlled equivalence classes. During both experiments, participants were trained with two different combinations of the same easily nameable, yet formally unrelated, pictorial stimuli. Match-to-sample baselines for eight four-member classes were established under the contextual control of two colors. In the presence of one color, conditional relations were established between stimuli whose normative names rhymed. In the presence of the other color, conditional relations were established between stimuli whose normative names did not rhyme. Although, during Experiment 1, all participants demonstrated equivalence classes involving rhyming stimuli, none demonstrated the formation of nonrhyme equivalence classes. To investigate this finding, Experiment 2 evaluated whether participants would demonstrate both rhyme and nonrhyme equivalence classes given more extensive exposure to the experimental contingencies. All participants demonstrated contextually controlled rhyme and nonrhyme equivalence classes, although rhyme classes were demonstrated with greater facility than nonrhyme classes. Results indicate that visual stimuli are named, that verbal bases for stimulus classification can affect the emergence of contextually controlled equivalence classes, and that untrained contextually controlled conditional discriminations involving novel stimuli can emerge on the basis of participants' verbal behavior.

Early intensive behavioral intervention for children with autism: therapists' perspectives on achieving procedural fidelity.

The variability in outcomes observed in home-based early intensive behavioral intervention for children with autism is likely in part to be the result of the quality of therapist performance. Therapist behavior in this context, however, is poorly understood. To achieve such an understanding, it will be necessary to specify how factors such as therapist, child and intervention program characteristics, as well as supervision and training provision, influence therapists' interactions with children. This study identified facilitating factors and barriers that therapists considered to influence their capacity to deliver early intensive behavioral intervention to young children with autism. Nineteen therapists associated with various service providers in the South of England were interviewed. In general, responses represented opposite poles of the same construct. For example, child factors such as compliance and competence were considered to facilitate instruction, whereas challenging behavior and lack of progress were perceived to hinder it. These issues are considered in the light of previous research on staff behavior in related contexts. The factors identified suggest specific avenues for questionnaire and experimental research to validate these findings, have implications for routine service provision and may help improve the outcomes of children receiving early intensive behavioral intervention.

Dissociation of wanting and liking for alcohol in humans: a test of the incentive-sensitisation theory.

RATIONALE: Incentive sensitisation theory (IST) claims that the mechanism of reward is comprised of separate neurobiological systems of wanting and liking, that dependent drug use occurs as a result of sensitisation of the system controlling wanting, and that the two systems can be dissociated. OBJECTIVE: To test the IST prediction that wanting and liking for alcohol can be dissociated in humans. METHODS: Measures of wanting and liking for alcohol were obtained in three experiments. Experiment 1 examined whether liking for alcohol was associated with levels of wanting, as indexed by self-reported weekly alcohol intake. Experiments 2 and 3 also assessed the association between liking and wanting but in these experiments wanting was also indexed by alcohol consumption in the laboratory. Experiment 2 increased wanting for alcohol using an alcohol priming dose to determine whether liking would be similarly affected. Experiment 3 reduced liking for alcohol by adulterating drinks with Tween to see whether wanting would also be reduced. RESULTS: Little evidence for an association between liking and wanting for alcohol was found in Experiments 1-3 but, collapsing across all experiments, a weak positive correlation between liking and wanting was found. However, in Experiment 2, wanting was increased by the alcohol priming dose whereas liking was not and in Experiment 3 liking was reduced without a concurrent reduction in wanting. CONCLUSIONS: Although correlations between wanting and liking can be observed these results support the contention of the IST that wanting and liking for alcohol can be dissociated in human participants.

Teaching children with autism when reward is delayed. The effects of two kinds of marking stimuli.

Three children with autism were taught to identify pictures of emotions in response to their spoken names. Their speed of acquisition was compared using a within-child alternating treatments design across three teaching conditions, each involving a 5 second delay to reinforcement. In the marked-before condition, an instruction encouraged the children to visually orient to the cards before they made their choice response; in the marked-after condition, an attention-eliciting verbal cue (e.g., "Look!") was delivered after both correct and incorrect responses; in the delay condition, these marking cues were omitted. Performance in the no-cue control was inferior to both the marked-before and marked-after conditions, but the difference between the latter two conditions was not significant.

Systems analysis of stress and positive perceptions in mothers and fathers of pre-school children with autism.

Systemic analyses of psychological functioning in families of children with autism have typically shown that parents report different experiences (e.g., stress) and that siblings may also be affected. The purpose of the present research was more explicitly to address relationships between child, partner, and parent variables. Parents of 48 children with autism (41 mother-father pairs) reported on child characteristics, and their own stress and mental health. Mothers were found to report both more depression and more positive perceptions than fathers. Regression analyses revealed that paternal stress and positive perceptions were predicted by maternal depression; maternal stress was predicted by their children's behavior problems (not adaptive behavior or autism symptoms) and by their partner's depression. The future testing of the mechanisms underlying these results is discussed. In addition, the need is emphasized for more systemic analyses to understand the psychological functioning of children with autism and their siblings and parents.

Coping strategies in mothers and fathers of preschool and school-age children with autism.

Despite the theoretical and demonstrated empirical significance of parental coping strategies for the wellbeing of families of children with disabilities, relatively little research has focused explicitly on coping in mothers and fathers of children with autism. In the present study, 89 parents of preschool children and 46 parents of school-age children completed a measure of the strategies they used to cope with the stresses of raising their child with autism. Factor analysis revealed four reliable coping dimensions: active avoidance coping, problem-focused coping, positive coping, and religious/denial coping. Further data analysis suggested gender differences on the first two of these dimensions but no reliable evidence that parental coping varied with the age of the child with autism. Associations were also found between coping strategies and parental stress and mental health. Practical implications are considered including reducing reliance on avoidance coping and increasing the use of positive coping strategies.

Acceptance and commitment therapy-based self-management versus psychoeducation training for staff caring for clients with a personality disorder: a randomized controlled trial.

People diagnosed with a personality disorder (PD) are often a stigmatized patient group. This can affect the care they receive, their progression, and the well-being of staff caring for them. Interventions targeted at health care professionals that aim to improve attitudes toward these patients and improve staff well-being do exist; however, evidence for their effectiveness is limited. The present study compared a self-management, Acceptance and Commitment Therapy-based training intervention (ACTr) with a Psychoeducation Training (PETr) intervention in their effectiveness in improving attitudes toward PD patients, staff-patient relations, and staff well-being. Both interventions were successful at improving attitudes and measures of staff-patient relations up to 6 months after training; however, staff well-being did not change for either group. The implications for staff training and future research are discussed.

Do executive deficits and delay aversion make independent contributions to preschool attention-deficit/hyperactivity disorder symptoms?

OBJECTIVE: To test whether deficits in executive function and delay aversion make independent contributions to levels of attention-deficit/hyperactivity disorder (ADHD) symptoms exhibited by preschool children. METHOD: One hundred fifty-six children between 3 and 5.5 years old (78 girls and 78 boys) selected from the community completed an age-appropriate battery of tests measuring working memory, set shifting, planning, delay of gratification, and preference for delayed rewards. Parents completed a clinical interview about their children's ADHD symptoms. RESULTS: Analysis of test performance revealed two factors: executive dysfunction and delay aversion. Multivariate analysis demonstrated that when other factors (i.e., age, IQ, and conduct problems) were controlled, executive dysfunction and delay aversion each made significant independent contributions to predictions of ADHD symptoms. CONCLUSIONS: Preschool ADHD symptoms are psychologically heterogeneous. Executive dysfunction and delay aversion may represent two distinct and early appearing neurodevelopmental bases for ADHD symptoms.

Are planning, working memory, and inhibition associated with individual differences in preschool ADHD symptoms?

The association between executive function (EF; planning, working memory, and inhibition) and individual differences in symptoms of attention deficit hyperactivity disorder (ADHD) was explored in a sample of preschool children. One hundred sixty children (between the ages of 3 years, 0 months and 5 years, 6 months), selected so as to oversample high ADHD scorers, performed 3 tasks previously shown to measure planning (Tower of London), working memory (Noisy Book) and inhibition ("Puppet Says..."). EF measures were reliable (kappa > .77) and were correlated with IQ (rs > .38) and age (rs > .59). Once IQ and age were controlled, planning and working memory (r = .41) were correlated. Planning and working memory were not correlated with inhibition (rs < .20). There was no association between ADHD and working memory or planning (rs < .12). There was a significant negative association between ADHD and conduct problems and inhibition (r = -.30 and r = -.25, respectively). Only the link with ADHD persisted after the effects of other factors were controlled for in a multiple regression. Specific deficits in inhibitory control rather than general EF deficits are associated with ADHD in the preschool period. This association is linear in nature, supporting the idea that ADHD is better seen as a continuum rather than a discrete category. This association provides evidence for Barkley's (1997) view that ADHD is underpinned by inhibitory deficits in the preschool period.

Teaching children with autism using conditioned cue-value and response-marking procedures: a socially valid procedure.

Five children with autism were taught to match printed words to corresponding pictures. Participants' speed of learning was compared across three training conditions, each involving a 5-s delay of reinforcement, using a within-participants alternating treatments design. In the cue-value condition, a verbal phrase of approval (e.g., "good!") was delivered only after correct responses and again after a 5-s delay when a primary reinforcer was delivered; in the response-marking condition, an attention-eliciting verbal cue (e.g., "look!") was delivered after both correct and incorrect responses, but not prior to the primary reinforcer; in the delay only condition, there were no cues during a 5-s delay. Performance in the no-cue control was inferior to both the cue-value and response-marking conditions, but there was little difference between the latter two conditions. The implications of these results for facilitating learning in applied settings are discussed.

Discrete-trial training for autistic children when reward is delayed: a comparison of conditioned cue value and response marking.

Three children with autism were taught to identify pictures of objects. Their speed of acquisition of receptive speech skills was compared across two conditions. In the cue-value condition, a compound audiovisual stimulus was presented after correct responses and again when a primary reinforcer was delivered after a 5-s delay; in the response-marking condition, a second stimulus was presented after both correct and incorrect responses, but not prior to the primary reinforcer. In both conditions primary reinforcement was delayed for 5 s. Although the children learned receptive speech skills in both conditions, acquisition was faster in the cue-value condition.

The development and initial validation of the cognitive fusion questionnaire.

Acceptance and Commitment Therapy (ACT) emphasizes the relationship a person has with their thoughts and beliefs as potentially more relevant than belief content in predicting the emotional and behavioral consequences of cognition. In ACT, "defusion" interventions aim to "unhook" thoughts from actions and to create psychological distance between a person and their thoughts, beliefs, memories, and self-stories. A number of similar concepts have been described in the psychology literature (e.g., decentering, metacognition, mentalization, and mindfulness) suggesting converging evidence that how we relate to mental events may be of critical importance. While there are some good measures of these related processes, none of them provides an adequate operationalization of cognitive fusion. Despite the centrality of cognitive fusion in the ACT model, there is as yet no agreed-upon measure of cognitive fusion. This paper presents the construction and development of a brief, self-report measure of cognitive fusion: The Cognitive Fusion Questionnaire (CFQ). The results of a series of studies involving over 1,800 people across diverse samples show good preliminary evidence of the CFQ's factor structure, reliability, temporal stability, validity, discriminant validity, and sensitivity to treatment effects. The potential uses of the CFQ in research and clinical practice are outlined.